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Minimally Invasive Surgery Options for Brain Tumor Patients

October 31, 2014

Top neurosurgeons reach deep into the brain, leaving barely a stitch behind.

It was the dead of winter—January—when Chantale Vante, MD, a 37-year-old internist in Huntington, N.Y., got an excruciating headache. She typically didn’t suffer from headaches, and this one persisted for nearly a week.

Though she was busy with a full docket of patients and her family (her sons are ages 4 and 2½), she knew she had to get checked out. Dr. Vante scheduled an examination, which led to an MRI. She was stunned by what it revealed. She had a meningioma, the most common type of benign brain tumor.

Meningiomas grow from the meninges, the covering of the brain between the brain and skull. If diagnosed and treated early, the prognosis is generally quite good. But Dr. Vante still had trouble digesting the news.

“At first I just couldn’t believe it. It was sort of surreal,” she says. “Any diagnosis of a tumor is frightening but especially when it’s so close to your brain.” And naturally, that diagnosis is pretty worrisome when you have two young children.

Dr. Vante knew that having the tumor removed sooner rather than later was the best bet for total recovery. “If meningiomas get too large you can have all sorts of problems, and it may mean you start reducing your options for the types of procedures that will be effective,” she explains.

The search for a neurosurgeon led Dr. Vante west to see Daniel Kelly, MD, director of the Brain Tumor Center and Pituitary Disorders Program at Providence Saint John’s Health Center in Santa Monica.

For patients like Dr. Vante, a new era of advances in neurosurgery is resulting in better outcomes and faster recoveries. Today, leading neurosurgeons can remove brain tumors and those of the skull base through smaller, more precise openings. In Southern California, Providence Health & Services neurosurgeons practice the latest techniques for brain, skull base and pituitary tumors.

Brain tumors, which can develop in people of all ages, are diagnosed in almost 70,000 Americans each year. The majority of cases, about 45,000, are benign (not cancerous) tumors. But these tumors can still be life-threatening because they can grow and impair brain and central nervous system functions.

Brain tumors that originate in the brain are called primary tumors; the most common types are meningiomas and gliomas (which grow from the supportive tissue in the brain). Metastatic tumors spread to the brain from cancerous tumors elsewhere in the body. Metastatic tumors are more common than primary brain tumors and most commonly come from lung cancer, breast cancer and melanoma (a skin cancer).

Whatever the type, neurosurgeons have made great strides in removing tumors while avoiding damage to the brain. Minimally invasive surgery—also known as keyhole surgery—is the concept of removing brain and skull base tumors in a way that minimizes the risk of collateral damage to the normal brain, nerves and critical blood vessels. It typically involves approaching tumors through smaller, more precise, openings in the scalp and skull or through the natural opening of the nose. Large, bony openings of the skull (known as a craniotomy) now are needed infrequently to remove tumors of the brain and skull base.

“The concept of keyhole surgery is really about sneaking in and out,” says Dr. Kelly. “We want to effectively remove the tumor with the absolute minimum of disruption to surrounding normal structures, promoting a more rapid and less painful recovery.”

Depending on the location of the tumor, keyhole surgery can be done through the nose (endonasal) or through a small bony opening through the eyebrow (supraorbital), behind the ear (retromastoid) or through other scalp openings. Working through these narrow corridors is greatly enhanced by use of an endoscope—a long, thin, surgical telescope equipped with a high-definition camera that provides surgeons with a panoramic, up-close and highly detailed view inside the head.

“Minimally invasive surgery results in faster recovery times, less pain and discomfort, a reduced risk of infection and fewer visible scars,” says Dr. Joung H. Lee, MD, who practices out of the Neurosurgery Center, a division of the Hycy and Howard Hill Neuroscience Institute at Providence Saint Joseph Medical Center in Burbank.
In recent years, leading neurosurgeons have become especially adept at avoiding retraction injuries, which is damage to the brain that occurs during the surgery, Dr. Lee says.

“Reducing retraction injury is really about minimizing the exposure of the brain to the outside elements, when possible, and minimizing the amount of brain manipulation while removing the tumor,” he says.

Dr. Vante had surgery through a small scalp incision in February at Saint John’s Health Center. The procedure lasted almost eight hours, but her recovery has been swift. She spent only 48 hours in the hospital.

“I was only out of work for about a month, and I was tired, of course, for a couple of months,” she says.

Patients who have skull base tumors—the most common of which are meningiomas and acoustic neuromas—also are benefiting from innovative procedures and technology. Skull base tumors, as the name implies, develop in a crowded and complicated part of the cranium below and along the sides of the brain. As they grow, they can encroach on the inner ear, the brain stem and the cranial nerves coming off the brain stem.

Acoustic neuromas, which arise along the nerves responsible for balance and hearing, can cause hearing loss in the affected ear, tinnitus, dizziness and even facial numbness. Similarly meningiomas of the skull base can cause these symptoms as well as difficulty swallowing, imbalance, difficulty walking and even visual loss or double vision.

Tumors in the skull base have been a challenge for neurosurgeons for decades. But, Dr. Lee says, “A better understanding of that region of the brain and improved surgical techniques now make tumor removal safer and more effective.”

Even patients with tumors that threaten vision or hearing often can be safely removed with a very low risk of long-lasting effects. For some skull base tumors that are not able to be completely removed or are relatively small, focused precision radiation (also known as radiosurgery) can be used to effectively halt tumor growth.
Providence neurosurgeons Kelly and Lee say their work has been assisted greatly in the last 10 to 15 years by advances in neuro-imaging, navigation techniques, ultrasound and better anatomical understanding. Surgeons can now create detailed pictures of the tumor from imaging studies prior to the surgery, or even during surgery, to help them locate the tumor and surrounding critical structures with precision.

“Our imaging and navigation, for example, have improved tremendously. We now have the ability to place a probe on the head and pinpoint a location within a few millimeters,” says Dr. Kelly. The result is often more complete tumor removal, less manipulation of the brain and other critical structures, less pain and shorter hospital stays.

The final ingredient of success is Providence’s team approach to comprehensive brain tumor care. Several specialists, depending on the tumor type and location, are often involved. For example, pituitary and midline skull base tumors removed through the endonasal endoscopic route, are performed in collaboration with an ear, nose and throat (ENT) surgeon. If radiation is required along with surgery, a radiation oncologist will be added to the team.

“We strongly believe in the idea that more eyes, more hands and more expertise translates into better outcomes,” says Dr. Kelly.

As for Dr. Vante, she is back to being a busy mom, wife and internist. There’s practically no evidence that she had the surgery; the incision on her scalp isn’t even visible through her hair. And the best news? Last week, a follow-up MRI three months after surgery showed no signs of any tumor.
“It’s hard to even express how elated I am – and how relieved,” she says.

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Providence Health & Services, Southern California, provides the South Bay, Westside and San Fernando Valley a full spectrum of care that includes leading-edge diagnostics and treatment, outpatient health centers, the well-regarded Providence Medical Institute, numerous outreach programs and clinics, hospice and home care and Providence High School, a Blue Ribbon college-preparatory campus.